At a recent grantee breakfast hosted by a corporate healthcare foundation, one of the attendees asked about the impact of the Affordable Care Act (ACA) on mainstream healthcare. The presenter named seismic shifts: outcomes-based measurement for reimbursement, integration of physical and mental health services and care coordination, using a team approach to assist patients in getting services outside the usual purview of healthcare such as food assistance, housing assistance and help with medications. I raised my hand and offered the services of the people in that room to teach—for a small fee—the mainstream healthcare providers how to do it. The room erupted in laughter and applause, but I wasn’t joking. The nonprofit sector has been at the forefront of all of those “revolutionary” ideas for years. This type of integration is in the DNA of most community-based organizations. I am still waiting for that call.
On January 1, 2014, there was much wailing and gnashing of teeth because of the rollout of the ACA’s most famous provision: the individual coverage mandate. That was the primary subject of most stories about the ACA, and people roundly praised it or criticized it based solely on that single provision. But the reach of the ACA had begun long before that, with several wonky-sounding provisions that only those in the healthcare world paid attention to. And yet, it is those less newsworthy provisions that have made the biggest impact on turning the healthcare world around and viewing healthcare and payment policy through a completely new lens. Or, at least, new to the healthcare system status quo. But to some outside mainstream healthcare, this seismic shift was simply business as usual. Those in the world of free and charitable clinics simply saw their way of doing business categorized as “revolutionary” and “game changing.”
Free and charitable clinics (FCCs) are a community’s response to a community need. There is no centralized bureaucracy operating the clinics, and most work independent of hospital systems, governments or large governing bodies. Unlike Federally Qualified Health Centers (FQHCs), FCCs rarely receive government funding. Most often do not take insurance of any kind (including Medicaid) and provide services to the uninsured or underinsured completely free or for a modest fee (which is waived if the patient cannot pay). According to the National Association of Free Clinics, there are approximately 1200 FCCs in the country. In my own state of Illinois, there are at least 50 clinics. Because of the variety and the geographic focus of the individual and unique place-centered services they provide, trying to put an exact number on how many operate is like trying to nail Jell-O to the wall. But the one thing that unites free and charitable clinics is the way they provide services designed to meet the needs of their community, rather than evaluating the worth of a program using cost as the deciding factor.
One of the lesser-known provisions of the ACA is healthcare workforce development. The U.S. is fast approaching shortages in some key areas—notably, nursing and primary care. This impending shortage is somewhat ironic, in that as the ACA gives more people access to regular primary care, the pool of providers available to care for them is shrinking. The ACA invests in programs to stem this shortfall, including nurse practitioner programs, nursing programs and medical student programs. As with most healthcare training, a rotation of clinicals is an integral part of the training. Particularly with nurse practitioner students, there is a huge shortfall in available spots because of the perception that having students will slow the provider down. In the current “production–for–pay” environment, most potential preceptors are not willing to risk the loss in pay that slower production may bring.
Free and charitable clinics, however, have stepped in to fill some of the need. The Family Health Partnership Clinic in Crystal Lake, Illinois, has a collaborative program with Rush University’s School of Nursing to bring NP students into the clinic for their clinical hours. “This environment is ideal for NP students,” says Dr. Martha Siomos, the preceptor at the Clinic, who brings between two and four students each semester. “Not only are they getting a high quality/high touch clinical experience, it presents issues they would never have encountered in a regular practice, and it opens their eyes to the satisfaction of working in a community based clinic.”
CommunityHealth, located in the West Town and Englewood neighborhoods of Chicago, is the largest free clinic in Illinois (and in the country) and provides similar opportunities for medical schools and residency training programs to learn how to care for the uninsured. “The work is challenging,” notes Judith Haasis, Executive Director. “But this next generation of physicians quickly develops the insight and skills required to truly help our vulnerable patient population. What can I do for the asthmatic patient with bronchitis whose apartment is cold, damp, and covered in mold? How can I convince the mother of three who feels isolated and is struggling with depression to join a support group? Where can the homeless patient keep his insulin refrigerated?”
These questions form the very basis of the ACA’s aim to drive providers into Coordinated Care Entities (CCEs). These networks, according to the ACA, should provide patients with a continuous stream of care that doesn’t stop at the hospital door. It requires hospitals and healthcare systems to form relationships with other community organizations so that the holistic needs of the patients can be addressed, not just the immediate physical health care needs. The ACA recognizes that patients are more than just their disease states; their health is impacted by where they live, how they obtain (or not) their food, and other socioeconomic situations including drug/alcohol abuse, domestic violence, and mental health.
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Most free and charitable clinics have always operated this way. In Normal, Illinois, Community Health Care Clinic’s executive director is a social worker who understands that health is not simply the “absence of disease”—it relates to everything in the patients’ world that impacts them. Recently, Community Health Care Clinic has taken that model to a new level. Partnering with the local homeless organization, the clinic brought its mobile health van to an encampment where many homeless people were living in tents and to the local homeless shelter. Most of them had never been to the clinic’s physical building, but took advantage of the proximity of the health van to get initial treatment for chronic and acute conditions as well as look at alternative housing options. Social workers were available to assess and refer those who were in need of further mental health and other community services. “It was a terrific opportunity to reach those who we thought were unreachable by bringing a one stop shop to them where they were and when they needed it,” noted Angie McLaughlin, Clinic Executive Director. “We have always been strong partners with the homeless agency, and this was a way that we each could deliver better services to a small community in need.” These two organizations don’t call their partnership a “coordinated care entity”; they simply call it business as usual.
These three clinics are not going the extra mile because of the promise of extra reimbursement—in fact, none of these programs are moneymakers—but because it is part of the holistic philosophy embraced by free and charitable clinics around the country. In addition, high-touch healthcare has proved to deliver better outcomes for patients.
Because of the heavy reliance on foundation grants and funding, free and charitable clinics and other nonprofit organizations exist in a world where outcomes-based measurements are critical. The VNA Foundation in Chicago, a strong funder of healthcare to the underserved, stresses a need for potential grantees to be able to show improvement in health status, rather than simply an increase in census numbers. An entire area of their website is dedicated to outcomes-based measurements, with grantee examples highlighted to assist others with measuring the value of the services they deliver.
That attention to outcomes has paid off. The Family Health Partnership Clinic (FHPC) can show that their patients with diabetes actually have A1cs (a measure of blood sugar control) that are lower than that of diabetic patients who have regular private insurance. FHPC does regular chart reviews and audits and looks at population health to determine how patients are doing as a whole. Few private offices are able to provide that kind of data. They can report how many diabetic patients they have, but they rarely look at the actual outcomes of the patients as a population.
The shift to outcome-based measurements as a condition for reimbursement and coordinated care is integral to the structure of the ACA, and is cited as one of the seismic shifts, yet FCCs have been involved in this type of quality review for years. “It never ceases to amaze me at how creative and innovative free and charitable clinics are,” notes Leslie Ramyk, executive director of the Illinois Association of Free and Charitable Clinics. “So many of the things that FCCs are already doing—like integrated mental health care in the clinic—are only now being looked at by the larger healthcare systems.”
In many ways, the innovative work and extremely low budgets of FCCs reminds me of the joke about how Ginger Rogers danced: She had to do everything Fred Astaire did, but backwards and wearing heels.
But free and charitable clinic leaders rarely wear heels. They make it difficult to haul in donated exam tables.
Suzanne Hoban is the executive director of the Family Health Partnership Clinic in Crystal Lake, Illinois.